Nipple discharge: role of ductoscopy in comparison with standard diagnostic tests

A comparative analysis of diagnostic values of high-frequency ultrasound and fiberoptic ductoscopy for pathologic nipple discharge

BACKGROUND

This study aimed to compare the diagnostic accuracy of high-frequency ultrasound (HFUS) and fiberoptic ductoscopy (FDS) for pathologic nipple discharge (PND).

METHODS

HFUS and FDS were conducted in 210 patients with PND (248 lesions) treated at our hospital. The diagnostic accuracy of these two methods was compared using pathological diagnosis as the standard.

RESULTS

Among 248 lesions, 16 and 15 of 16 malignant lesions were accurately diagnosed by HFUS and FDS, respectively. Of 232 benign lesions, 183 and 196 cases were accurately diagnosed by HFUS and FDS, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HFUS in diagnosis of intraductal lesions were 84.36% (95% CI 79.26-88.39%), 60% (95% CI 23.07-92.89%), 96.03% (95% CI 96.55-99.83%), and 7.31% (95% CI 2.52-19.4%) respectively. The sensitivity, specificity, PPV, and NPV of FDS in diagnosis of intraductal lesions were 86.83% (95% CI 82.00-90.52%), 100% (95% CI 56.55-100%), 100% (95% CI 98.21-100%), and 13.51% (95% CI 5.91-27.98%) respectively. Diagnostic accuracy rates of HFUS and FDS were 83.87% (208/248) and 85.08% (211/248), respectively, exhibiting no statistically differences (χ² = 0.80, P > 0.05). The accuracy of HFUS combined with FDS was 93.14% (231/248), showing statistically differences (χ² = 10.91, P < 0.05).

CONCLUSIONS

Both HFUS and FDS demonstrated high diagnostic values for PND. HFUS has the advantage of non-invasive for nipple discharge with duct ectasia, exhibited good qualitative and localization diagnostic values. It is the preferred evaluation method for patients with nipple discharge. When HFUS cannot identify the cause of PND, FDS can be considered.

Meta-analysis and cost-effectiveness of ductoscopy, duct excision surgery and MRI for the diagnosis and treatment of patients with pathological nipple discharge

INTRODUCTION

Pathological nipple discharge (PND) is a common breast-related complaint for referral to a surgical breast clinic because of its association with breast cancer. The aim of this meta-analysis was to compare the diagnostic efficacy of magnetic resonance imaging (MRI) and ductoscopy in patients with PND. Additionally, we determined the most cost-efficient strategy for the treatment of PND and the detection of breast cancer in PND patient without radiological suspicion for malignancy.

MATERIALS AND METHODS

PubMed and EMBASE were searched to collect the relevant literature from the inception of both diagnostic methods until January 27th 2020. The search yielded 815 original citations, of which 10 studies with 894 patients were finally included for analysis. Costs of ductoscopy, MRI and duct excision surgery were obtained from the UMC Utrecht as established in the year 2019. These costs included: medical personnel, overhead costs, material costs and sterilisation costs.

RESULTS

The meta-analysis showed no significant difference in sensitivity between ductoscopy (44%) and MRI (76%) for the detection of malignancy in patients with PND. However, ductoscopy (98%) had a statistically significantly higher specificity than MRI (84%). Individual costs were €1401.33, €822.13 and €6494.27 for ductoscopy, MRI and duct excision surgery, respectively. Full diagnostic strategy involving ductoscopy was on average €1670.97, while with MRI it was €2070.27.

CONCLUSION

Patients undergoing MRI are more often (false) positive which more often leads to duct excision surgery referrals compared to ductoscopy. This makes ductoscopy significantly more cost-effective compared MRI in patients with PND without radiological suspicion for malignancy.

Network Meta-analysis for the Diagnostic Approach to Pathologic Nipple Discharge

Pathologic nipple discharge (PND) is one of the most common breast-related complaints for referral because of its supposed association with breast cancer. The aim of this network meta-analysis (NMA) was to compare the diagnostic efficacy of ultrasound, mammogram, cytology, magnetic resonance imaging (MRI), and ductoscopy in patients with PND, as well as to determine the best diagnostic strategy to assess the risk of malignancy as cause for PND. Cochrane Library, PubMed, and Embase were searched to collect relevant literature from the inception of each of the diagnostic methods until January 27, 2020. The search yielded 1472 original citations, of which 36 studies with 3764 patients were finally included for analysis. Direct and indirect comparisons were performed using an NMA approach to evaluate the combined odd ratios and to determine the surface under the cumulative ranking curves (SUCRA) of the diagnostic value of different imaging methods for the detection of breast cancer in patients with PND. Additionally, a subgroup meta-analysis comparing ductoscopy to MRI when conventional imaging was negative was also performed. According to this NMA, sensitivity for detection of malignancy in patients with PND was highest for MRI (83%), followed by ductoscopy (58%), ultrasound (50%), cytology (38%), and mammogram (22%). Specificity was highest for mammogram (93%) followed by ductoscopy (92%), cytology (90%), MRI (76%), and ultrasound (69%). Diagnostic accuracy was the highest for ductoscopy (88%), followed by cytology (82%), MRI (77%), mammogram (76%), and ultrasound (65%). Subgroup meta-analysis (comparing ductoscopy to MRI when ultrasound and mammogram were negative) showed no significant difference in sensitivity, but ductoscopy was statistically significantly better with regard to specificity and diagnostic accuracy. The results from this NMA indicate that although ultrasound and mammogram may remain low-cost useful first choices for the detection of malignancy in patients with PND, ductoscopy outperforms most imaging techniques (especially MRI) and cytology.

Interventional Ductoscopy as an Alternative for Major Duct Excision or Microdochectomy in Women Suffering Pathologic Nipple Discharge: A Single-center Experience

INTRODUCTION

Pathologic nipple discharge (PND) is, after palpable lumps and pain, the most common breast-related reason for referral to the breast surgeon and is associated with breast cancer. However, with negative mammography and ultrasound, the chance of PND being caused by malignancy is between 5% and 8%. Nevertheless, most patients with PND still undergo surgery in order to rule out malignancy. Ductoscopy is a minimally invasive endoscopic technique that enables direct intraductal visualization. The aim of this study was to evaluate (interventional) ductoscopy as an alternative to surgery in patients with negative conventional imaging.

MATERIALS AND METHODS

All patients with PND referred between 2010 and 2017 to our hospital for ductoscopy were retrospectively analyzed. Ductoscopy procedures were performed under local anesthesia in the outpatient clinic. The follow-up period was at least 3 months, and the primary outcome was the number of prevented surgical procedures. Furthermore, we evaluated possible complications after ductoscopy (infection and pain).

RESULTS

A total of 215 consecutive patients undergoing ductoscopy were analyzed. In 151 (70.2%) patients, ductoscopy was successful. In 102 procedures, an underlying cause for PND was visualized, of which 34 patients could be histologically proven and 82 patients treated. Sixty of the 215 patients were eventually operated, 8 owing to suspicious findings during ductoscopy, 42 owing to persistent PND, and 10 because of recurrent PND. In 7 patients, a malignancy was found (5 of them classified as suspicious at dusctoscopy). No serious side effects were seen.

CONCLUSION

Ductoscopy can be safely used as an alternative for surgery in the workup for PND.

Evaluation and management of pathological nipple discharges without using intraductal imaging methods

BACKGROUND

The most common cause of pathological nipple discharge (PND) is single papilloma, which is a benign intraductal lesion (BIL). However, underlying malign (MIL) or high-risk intraductal lesions (HIL) should be considered during examination.

AIM

To reveal the value of conventional imaging methods (CIM), discharge characteristics, and cytology in lack of intraductal imaging methods to detect intraductal lesions (IL) and MIL that cause PND.

METHODS

We compared the pathological findings with the characteristics of discharge, CIM, and cytology findings of the patients who admitted to our clinic with nipple discharge and underwent duct excision (n = 111).

RESULTS

IL were detected in 69 (62.2%) patients as BIL (n = 31), HIL (n = 23), and MIL (n = 15). Most of the IL was observed with bloody, serosanguineous, and serous discharges (83.3%, 76.2%, and 69.2%, respectively). The sensitivities of ultrasonography, MRI, and cytology in detecting IL were found to be 50.7%, 42.6%, and 74.1%, while their specificities were found to be 73.8%, 88.2%, and 48.6%, respectively. None of the CIM was sufficient to detect MIL in 5 (33.3%) patients. The appearance of red blood cells detailed in cytology was significantly related to IL (p < 0.01), whereas the presence of inflammatory cells was related to ductal ectasia and periductal mastitis (p < 0.001).

CONCLUSIONS

Although patients' physical examinations, CIM, and cytology findings were normal, duct excision procedures should be applied to exclude MIL or HIL, which can be a cause of discharge in case of suspicious color. The details in cytology reports have a role in increasing the value of cytology.

Use of fiberoductoscopy for the management of patients with pathological nipple discharge: experience of a single center in Poland

BACKGROUND

Pathological nipple discharge (PND) is associated with serious clinical and diagnostic issues. Fiberoductoscopy (FDS) is a new diagnostic option in PND patients. This study summarizes our initial experience of FDS for the management of PND patients in a single center in Poland and assesses its safety.

METHODS

A total of 256 women with PND were included in this prospective, case-controlled, single-center study between 2006 and 2014. Of the 250 patients who underwent FDS, 154 had mammary duct lesions and 96 had no visible lesions. Subsequently, 129 patients with lesions identified by FDS underwent microductectomy and the lesions were pathologically evaluated.

RESULTS

The mean duration of FDS examination was 17 min. The most frequent intraductal lesion was amputation of a duct (35.1%), followed by circular narrowing or hyperplasia (22.7%). Final histological findings were unremarkable in 11.6% of cases, whereas mammary duct papilloma, duct ectasia, and ductal carcinoma in situ were detected in 71.3, 10.9, and 6.2% of cases, respectively.

CONCLUSIONS

FDS is an innovative method for visualizing intraductal mammary lesions and allows accurate selection of mammary ducts with suspicious lesions that require surgical removal in women with PND.

Diagnosis of Nipple Discharge: Value of Magnetic Resonance Imaging and Ultrasonography in Comparison with Ductoscopy

Background:

Pathologic nipple discharge, which is a common reason for referral to the breast imaging service, refers to spontaneous or bloody nipple discharge that arises from a single duct. The most common cause of nipple discharge is benign breast lesions, such as solitary intraductal papilloma and papillomatosis. Nevertheless, in rare cases, a malignant cause of nipple discharge can be found.

Aims:

To study the diagnostic value of ultrasonography, magnetic resonance imaging, and ductoscopy in patients with pathologic nipple discharge, compare their efficacy, and investigate the importance of magnetic resonance imaging in the diagnosis of intraductal pathologies.

Study Design:

Diagnostic accuracy study.

Methods:

Fifty patients with pathologic nipple discharge were evaluated by ultrasonography and magnetic resonance imaging. Of these, 44 ductoscopic investigations were made. The patients were classified according to magnetic resonance imaging, ultrasonography, and ductoscopy findings. A total of 25 patients, whose findings were reported as intraductal masses, underwent surgery oincluding endoscopic excision for two endoscopic excision. Findings were compared with the pathology results that were accepted as the gold standard in the description of the aetiology of nipple discharge. In addition, magnetic resonance imaging, ultrasonography and ductoscopy findings were analysed comparatively in patients who had no surgery.

Results:

Intraductal masses were reported in 26 patients, 20 of whom operated and established accurate diagnosis of 18 patients on magnetic resonance imaging. According to the ultrasonography, intraductal masses were identified in 22 patients, 17 of whom underwent surgery. Ultrasonography established accurate diagnoses in 15 patients. Intraductal mass was identified in 22 patients and ductoscopy established accurate diagnoses based on histopathologic results in 16 patients. The sensitivities of methods were 75% in ultrasonography, 90% in magnetic resonance imaging, and 94.6% in ductoscopy. The specificities were 66.7% in ultrasonography, 66.7% in magnetic resonance imaging, and 40% in ductoscopy. Intraductal papillomas were mostly observed as oval nodules with well-circumscribed smooth margins within dilated ducts and persistant in the dynamic analysis. Lesions that protruded into the lumen of the ducts, either solitary or multiple, were characteristic ductoscopy findings of our patients who were diagnosed as having papilloma/papillomatosis.

Conclusion:

Magnetic resonance imaging and ductoscopy had no statistical superiority over each other, however they were superior to ultrasonography in the diagnosis of pathologic nipple discharge. Magnetic resonance imaging may be highly sensitive for diagnosing nipple discharge with new techniques and sequences and a non-invasive method that more advantageous for showing ductal tree visualization and is able to detect completely obstructed intraductal lesions.

Diagnostic Performance of MRI Versus Galactography in Women With Pathologic Nipple Discharge: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of our study was to perform a systematic review of the literature of the diagnostic accuracy of MRI compared with galactography in women with pathologic nipple discharge.

MATERIALS AND METHODS

A systematic literature search was performed (MEDLINE, Embase, Web of Science) for articles evaluating the diagnostic performance of MRI and galactography in patients with pathologic nipple discharge and with histologic verification or clinical follow-up. Distinction between any abnormality and cancer was made. Two independent readers selected eligible articles published until December 2015. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Data analyses were performed using the bivariate model.

RESULTS

Ten articles were analyzed for a total of 921 patients. The study quality was high, with a low risk of bias and low concerns regarding applicability. The pooled sensitivity for any abnormality was significantly higher for MRI, with 92% (95% CI, 85-96%), than for galactography, with 69% (95% CI, 59-78%) (p < 0.001). The pooled specificity was 76% (95% CI, 49-92%) for MRI versus 39% (95% CI, 16-69%) for galactography (p < 0.001). The pooled sensitivity and specificity for cancer detection were calculated for MRI only and were 92% (95% CI, 74-98%) and 97% (95% CI, 80-100%), respectively.

CONCLUSION

This meta-analysis shows a higher diagnostic performance of MRI compared with that of galactography in the detection of any kind of lesion in patients with pathologic nipple discharge. Moreover, high sensitivity and very high specificity for cancer by MRI could be confirmed in this clinical setting. If mammography and ultrasound are negative, MRI should be preferred over galactography for further evaluation.

Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge

Background

Invasive surgery remains the standard for diagnosis of pathological nipple discharge (PND). Only a minority of patients with nipple discharge and an unsuspicious finding on conventional breast imaging have cancer. Ductoscopy is a minimally invasive alternative for evaluation of PND. This systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of ductoscopy in patients with PND.

Methods

A systematic search of electronic databases for studies addressing ductoscopy in patients with PND was conducted. Two classification systems were assessed. For DSany, all visualized ductoscopic abnormalities were classified as positive, whereas for DSsusp, only suspicious findings were considered positive. After checking heterogeneity, pooled sensitivity and specificity of DSany and DSsusp were calculated.

Results

The search yielded 4642 original citations, of which 20 studies were included in the review. Malignancy rates varied from 0 to 27 per cent. Twelve studies, including 1994 patients, were eligible for meta-analysis. Pooled sensitivity and specificity of DSany were 94 (95 per cent c.i. 88 to 97) per cent and 47 (44 to 49) per cent respectively. Pooled sensitivity and specificity of DSsusp were 50 (36 to 64) and 83 (81 to 86) per cent respectively. Heterogeneity between studies was moderate to large for sensitivity (DSany: I2 = 17·5 per cent; DSsusp: I2 = 37·9 per cent) and very large for specificity (DSany: I2 = 96·8 per cent; DSsusp: I2 = 92·6 per cent).

Conclusion

Ductoscopy detects about 94 per cent of all underlying malignancies in patients with PND, but does not permit reliable discrimination between malignant and benign findings.

Does Nipple Discharge Color Predict (pre-) Malignant Breast Pathology?

Unilateral single-duct nipple discharge is associated with an increased risk for underlying breast malignancy. There is no consensus whether color of nipple discharge independently indicates the risk of malignancy. We sought to assess the relationship between the color of discharge and the risk of malignancy. Patients with unilateral single-duct nipple discharge without abnormalities on clinical and radiologic examination were included. Prior to diagnostic microdochectomy nipple discharge characteristics were registered. Multiple logistic regressions were performed to assess the relationship between color of nipple discharge and malignancy, corrected for age. During a mean follow-up period of 7.1 years we determined complication rate and false-negative rate of microdochectomy. A total of 184 patients were included (median age 53 years, range 19-84). Histologic examination revealed (in situ or invasive) breast carcinoma in 10.9% (20) of patients and high-risk lesions in 11.4% (21). Malignancy or high-risk lesions were found in 25% (OR: 1.37; 95% CI: 0.62-3.00) of patients with bloody discharge. Risk of underlying malignancy increased in patients >60 years (OR: 2.35; 95% CI: 1.14-4.83). Complication rate of microdochectomy was 2.7%. Single-duct, unilateral nipple discharge is a sign of underlying malignancy in a substantial proportion of cases. The majority of patients with unilateral single-duct nipple discharge, diagnosed with breast cancer, present with bloody discharge. However, the association between bloody nipple discharge and malignancy is not strong enough to distinguish high-risk patients. Therefore, invasive diagnostic procedures like microdochectomy should be offered to all patients with unilateral uniductal nipple discharge to search for underlying malignancy.

Evaluation of Pathologic Nipple Discharge: What is the Added Diagnostic Value of MRI?

PURPOSE

To determine the diagnostic value of magnetic resonance imaging (MRI) for the evaluation of patients with pathologic nipple discharge.

METHODS

We performed a retrospective review of women with nipple discharge who underwent breast MRI between January 1, 2004, and December 31, 2013. Radiographic findings, pathology results, and clinical notes were reviewed. Sensitivity, specificity, positive predictive value, and negative predictive value of MRI were calculated.

RESULTS

Over a 10-year period, 103 women (mean age 46 years, range 25-72 years) underwent MRI for evaluation of nipple discharge. Ninety-one patients (88 %) underwent surgical excision or had clinical and/or radiographic follow-up at least 2 years after presentation and thus comprise the study population. Eleven (30 %) of 37 patients with MRIs coded as American College of Radiology Breast Imaging-Reporting and Data System (BI-RADS) 4 of 5 were diagnosed with ductal carcinoma in situ (n = 6) or invasive adenocarcinoma (n = 5). Seven (64 %) of 11 patients diagnosed with malignancy had a negative mammographic and sonographic workup. None of the patients with MRIs coded as BI-RADS 1, 2, or 3 was diagnosed with malignancy immediately after presentation or during the 2-year follow-up period. The sensitivity and specificity of MRI for the detection of malignancy were 100 % (11 of 11) and 68 % (54 of 80), respectively. The positive predictive value and negative predictive value were 37 and 100 %, respectively.

CONCLUSIONS

MRI is a valuable additional diagnostic tool for the evaluation of pathologic nipple discharge when conventional imaging is negative. A negative MRI in this symptomatic population may obviate the need for duct exploration and excision.

Mammary ductoscopy and follow-up avoid unnecessary duct excision in patients with pathologic nipple discharge

BACKGROUND AND OBJECTIVES

The goal of this study was to evaluate the efficacy of ductoscopy and follow-up for the diagnoses of intraductal lesions and the concomitant advantages of avoiding surgery for patients with pathologic nipple discharge (PND).

METHODS

Two hundred and sixty-six ductoscopies were performed for 238 women. Patients with positive ductoscopies underwent surgery. If no positive lesions were present upon ductoscopy, the women were followed.

RESULTS

Of 266 ductoscopic examinations, 168 (63.2%, 168/266) breasts from 165 patients were found to have positive images. The final histopathological results revealed that 93 patients with intraductal papilloma, 42 with intraductal papillomatosis, 15 with ADH lesions, DCIS in 9 patients, 1 case with invasive ductal carcinoma (IDC), 6 cases with duct ectasia, and 2 cases with inflammation. Seventy-three patients with negative results upon ductoscopy were followed with a median time of 48 months. Twelve patients had PND recurrence and were diagnosed as papilloma or papillomatosis based on pathology after surgery. PND disappeared for 51 patients after ductoscopy, and no recurrence or disease evolvement was founded for them.

CONCLUSION

Ductoscopy and follow-up were advantageous for selecting patients to undergo surgery or surveillance. The recurrence of PND after ductoscopy might be a strong predictor for having intraductal disease.

3.0 Tesla breast magnetic resonance imaging in patients with nipple discharge when mammography and ultrasound fail

OBJECTIVES

To compare 3.0 Tesla breast magnetic resonance imaging (MRI) with galactography for detection of benign and malignant causes of nipple discharge in patients with negative mammography and ultrasound.

METHODS

We prospectively evaluated 56 breasts of 50 consecutive patients with nipple discharge who had inconspicuous mammography and ultrasound, using 3.0 Tesla breast MRI with a dedicated 16-channel breast coil, and then compared the results with galactography. Histopathological diagnoses and follow-ups were used as reference standard. Lesion size estimated on MRI was compared with the size at histopathology.

RESULTS

Sensitivity and specificity of MRI vs. galactography for detecting pathologic findings were 95.7 % vs. 85.7 % and 69.7 % vs. 33.3 %, respectively. For the supposed concrete pathology based on MRI findings, the specificity was 67.6 % and the sensitivity 77.3 % (PPV 60.7 %, NPV 82.1 %). Eight malignant lesions were detected (14.8 %). The estimated size at breast MRI showed excellent correlation with the size at histopathology (Pearson's correlation coefficient 0.95, p < 0.0001).

CONCLUSIONS

MRI of the breast at 3.0 Tesla is an accurate imaging test and can replace galactography in the workup of nipple discharge in patients with inconspicuous mammography and ultrasound.

KEY POINTS

• Breast MRI is an excellent diagnostic tool for patients with nipple discharge. • MRI of the breast reveals malignant lesions despite inconspicuous mammography and ultrasound. • MRI of the breast has greater sensitivity and specificity than galactography. • Excellent correlation of lesion size measured at MRI and histopathology was found.